Although no psychiatric or psychological organization has sanctioned a diagnosis titled "psychopathy", assessments of psychopathic characteristics are widely used in criminal justice settings in some nations, and may have important consequences for individuals.[5] The term is also used by the general public, in popular press, and in fictional portrayals.[6]

Researchers have noted that there appear to be at least two different conceptions of psychopathy, each with differing policy implications. Jennifer L. Skeem et al. distinguished Cleckleyan psychopathy (named after Hervey Cleckley's early conception of psychopathy, entailing bold, disinhibited behavior, low anxiety and "feckless disregard") and criminal psychopathy (a "meaner, more aggressively disinhibited conception of psychopathy that explicitly entails persistent and sometimes serious criminal behavior", typically operationalized with the Hare Psychopathy Checklist). Due to the profound implications that a label of "psychopath" can have—including in terms of decisions about punishment severity, treatment, etc.—efforts have been made to clarify the meaning of the term, e.g. by reconciling seemingly disparate conceptions such as those mentioned.[1]

The triarchic model, formulated by Christopher J. Patrick et al., suggests that different conceptions of psychopathy emphasize three observable characteristics to varying degrees. Analyses have been made with respect to the applicability of measurement tools such as the Hare Psychopathy Checklist (PCL, PCL-R) and Psychopathic Personality Inventory (PPI) to this model.[1][7]

Boldness. Low fear including stress-tolerance, toleration of unfamiliarity and danger, and high self-confidence and social assertiveness. The PCL-R measures this relatively poorly and mainly through Facet 1 of Factor 1. Similar to PPI Fearless dominance. May correspond to differences in the amygdala and other neurological systems associated with fear.[1][7]

Disinhibition. Poor impulse control including problems with planning and foresight, lacking affect and urge control, demand for immediate gratification, and poor behavioral restraints. Similar to PCL-R Factor 2 and PPI Impulsive antisociality. May correspond to impairments in frontal lobe systems that are involved in such control.[1][7]

Meanness. Lacking empathy and close attachments with others, disdain of close attachments, use of cruelty to gain empowerment, exploitative tendencies, defiance of authority, and destructive excitement seeking. The PCL-R in general is related to this but in particular some elements in Factor 1. Similar to PPI Coldheartedness but also includes elements of subscales in Impulsive antisociality. Meanness may possibly be caused by either high boldness or high disinhibition combined with an adverse environment. A child with high boldness may respond poorly to punishment but may respond better to rewards and secure attachments which may not be available under adverse conditions. A child with high disinhibition may have increased problems under adverse conditions with meanness developing in response.[1][7]

An early and influential analysis from Harris and colleagues indicated a discrete category may underlie PCL-R psychopathy, but this was only found for the behavioral Factor 2 items.[8] Marcus, John, and Edens more recently performed a series of statistical analyses on PPI scores and concluded psychopathy may best be conceptualized as having a "dimensional latent structure" like depression.[9]

Marcus et al. repeated the study on a larger sample of prisoners, using the PCL-R and seeking to rule out other experimental or statistical issues that may have produced the previously different findings. They again found that the psychopathy measurements do not appear to be identifying a discrete type (a taxon). They suggest that while for legal or other practical purposes an arbitrary cut-off point on trait scores might be used, there is actually no clear scientific evidence for an objective point of difference by which to call some people "psychopaths;" in other words, a "psychopath" may be more accurately described as someone who is "relatively psychopathic".[1][10]

The PCL-R was developed for research, not clinical forensic diagnosis, and even for research purposes to improve understanding of the underlying issues, it is necessary to examine dimensions of personality in general rather than only a constellation of traits.[1][11]

There are different views as to which personality dimensions are more central in regard to psychopathy.[12] Besides dimensions described elsewhere in this article, studies have linked psychopathy to alternative dimensions,[12][13][14] such as antagonism (high), conscientiousness (low) and anxiousness (low, or sometimes high).[12] Psychopathy has also been linked to high psychoticism—a theorized dimension referring to tough, aggressive or hostile tendencies.[13] Aspects of this that appear associated with psychopathy are lack of socialization and responsibility, impulsivity, sensation-seeking (in some cases), and aggression.[13]

Otto Kernberg, from a particular psychoanalytic perspective, believed psychopathy should be considered as part of a spectrum of pathological narcissism, that would range from narcissistic personality on the low end, malignant narcissism in the middle, and psychopathy at the high end.[14] However, narcissism is generally seen as only one possible aspect of psychopathy as broadly defined.

In terms of simple correlations, the PCL-R manual states an average score of 22.1 has been found in North American prisoner samples, and that 20.5% scored 30 or higher. An analysis of prisoner samples from outside North America found a somewhat lower average value of 17.5.[21] Studies have found that psychopathy scores correlated with repeated imprisonment, detention in higher security, disciplinary infractions, and substance misuse.[22]

Psychopathy, as measured with the PCL-R in institutional settings, shows in meta-analyses small to moderate effect sizes with institutional misbehavior, postrelease crime, or postrelease violent crime with similar effects for the three outcomes. Individual studies give similar results for adult offenders, forensic psychiatric samples, community samples, and youth. The PCL-R is poorer at predicting sexual re-offending. This small to moderate effect appears to be due largely to the scale items that assess impulsive behaviors and past criminal history, which are well-established but very general risk factors. The aspects of core personality often held to be distinctively psychopathic generally show little or no predictive link to crime by themselves. For example, Factor 1 of the PCL-R and Fearless dominance of the PPI-R have smaller or no relationship to crime, including violent crime. In contrast, Factor 2 and Impulsive antisociality of the PPI-R are associated more strongly with criminality. Factor 2 has a relationship of similar strength to that of the PCL-R as a whole. The antisocial facet of the PCL-R is still predictive of future violence after controlling for past criminal behavior which, together with results regarding the PPI-R which by design does not include past criminal behavior, suggests that impulsive behaviors is an independent risk factor.[1] Thus, the concept of psychopathy may perform poorly when attempted to be used as a general theory of crime.[23]

Studies have suggested a strong correlation between psychopathy scores and violence, and the PCL-R emphasizes features that are somewhat predictive of violent behavior.[1][24] Researchers, however, have noted that psychopathy is dissociable from and not synonymous with violence.[1]

It has been suggested that psychopaths tend to commit more "instrumental" violence than "reactive" violence. One conclusion in this regard was made by a 2002 study of homicide offenders, which reported that the homicides committed by psychopaths were almost always (93.3%) primarily instrumental, while about half (48.4%) of those committed by non-psychopaths were.[25] However, contrary to the equating of this to mean "in cold blood", more than a third of the homicides by psychopaths involved emotional reactivity as well. In addition, the non-psychopaths still accounted for most of the instrumental homicides, because most of these murderers were not psychopaths. In any case, FBI profilers indicate that serious victim injury is generally an emotional offense, and some research supports this, at least with regard to sexual offending. One study has found more serious offending by non-psychopaths on average than by psychopaths (e.g. more homicides versus more armed robbery and property offenses) and another that the Affective facet of the PCL-R predicted reduced offense seriousness.[1]

Although psychopathy is associated with an increased risk of violence, it is difficult to know how to manage the risk.[26] Some clinicians suggest that assessment of the construct of psychopathy does not necessarily add value to violence risk assessment.[1][27][28] A large systematic review and meta-regression found that the PCL performed the poorest out of nine tools for predicting violence.[29][30] In addition, studies conducted by the authors or translators of violence prediction measures, including the PCL, show on average more positive results than those conducted by more independent investigators.[31] There are several other risk assessment instruments which can predict further crime with an accuracy similar to the PCL-R and some of these are considerably easier, quicker, and less expensive to administrate. This may even be done automatically by a computer simply based on data such as age, gender, number of previous convictions and age of first conviction. Some of these assessments may also identify treatment change and goals, identify quick changes that may help short-term management, identify more specific kinds of violence that may be at risk, and may have established specific probabilities of offending for specific scores. Nonetheless, the PCL-R may continue to be popular for risk assessment because of its pioneering role and the large amount of research done using it.[1][27]

A 2011 study of conditional releases for Canadian male federal offenders found that psychopathy was related to more violent and non-violent offences but not more sexual offences. For child molesters, psychopathy was associated with more offences. It is purported that high-psychopathy offenders (both sexual and non-sexual offenders) are about 2.5 times more likely to be granted conditional release compared to non-psychopathic offenders.[33]

Some researchers have argued that psychopaths have a preference for violent sexual behavior.[34] A study examining the relationship between psychopathy scores and types of aggression in a sample of sexual murderers, in which 84.2% of the sample had PCL-R scores above 20 and 47.4% above 30, found that 82.4% of those with scores above 30 had engaged in sadistic violence (defined as enjoyment indicated by self-report or evidence) compared to 52.6% of those with scores below 30, and total PCL-R and Factor 1 scores correlated significantly with sadistic violence.[35]

In considering the issue of possible reunification of some sex offenders into homes with a non-offending parent and children, it has been advised that any sex offender with a significant criminal history should be assessed on the PCL-R, and if they score 18 or higher than they should be excluded from any consideration of being placed in a home with children under any circumstances.[36] There is, however, increasing concern that PCL scores are too inconsistent between different examiners, including in its use to evaluate sex offenders.[37]

Researchers have discussed the possibility of psychopathy being associated with organised crime, economic crime and war crimes.[38]Terrorists are sometimes called psychopaths, and comparisons may be drawn with traits such as antisocial violence, a selfish world view that precludes the welfare of others, a lack of remorse or guilt, and blame externalization. However, John Horgan, author of The Psychology of Terrorism, argues that such comparisons could also then be drawn more widely: for example, to soldiers in wars. It has also been noted that coordinated terrorist activity requires organization, loyalty and ideology, and that traits such as a self-centered disposition, unreliability, poor behavioral controls, and unusual behaviors may be disadvantages.[39]

It has been speculated that some psychopaths may be socially successful, due to factors such as low disinhibition as defined in the triarchic model, in combination with other advantages such as a favorable upbringing and good intelligence. However, there is little research on this, in part because the PCL-R does not include positive adjustment characteristics, and most researchers have used the PCL-R on incarcerated criminals. Some research using the PPI report that some interpersonal and affective traits associated with psychopathy, and boldness and/or meanness as defined in the triarchic model, can exist in non-criminals and correlate with stress immunity and stability.[1] Psychologists Fritzon and Board, in their study comparing the incidence of personality disorders in business executives against criminals detained in a mental hospital, found that the profiles of senior business managers contained some significant elements of personality disorders, particularly those referred to as the "emotional components" of psychopathy.[40]

The PCL:YV is an adaptation of the PCL-R for individuals aged 13–18 years. It is, like the PCL-R, done by a trained rater based on an interview and an examination of criminal and other records. The "Antisocial Process Screening Device" (APSD) is also an adaptation of the PCL-R. It can be administered by parents or teachers for individuals aged 6–13 years. High psychopathy scores for both juveniles, as measured with these instruments, and adults, as measured with the PCL-R and other measurement tools, have similar associations with other variables, including similar ability in predicting violence and criminality.[1][41][42]

There are moderate to high correlations between psychopathy rankings from late childhood to early adolescence. The correlations are considerably lower from early- or mid-adolescence to adulthood. In one study most of the similarities were on the Impulsive- and Antisocial-Behavior scales. Of those adolescents who scored in the top 5% highest psychopathy scores at age 13, less than one third (29%) were classified as psychopathic at age 24. Some recent studies have also found poorer ability at predicting long-term, adult offending. In one study, predictive ability was found to be not better than unaided clinical judgment.[1]

Juvenile psychopathy appears to be associated with more negative emotionality such as anger, hostility, anxiety, and depression.[1]

Conduct disorder is diagnosed based on a prolonged pattern of antisocial behavior in childhood and/or adolescence, and may be seen as a precursor to ASPD.[43][44] Some researchers have speculated that there are two subtypes of conduct disorder which mark dual developmental pathways to adult psychopathy.[1]

The DSM allows differentiating between childhood onset before age 10 and adolescent onset at age 10 and later. Childhood onset is argued to be more due to a personality disorder caused by neurological deficits interacting with an adverse environment. For many, but not all, childhood onset is associated with what is in Terrie Moffitt's developmental theory of crime referred to as "life-course- persistent" antisocial behavior as well as poorer health and economic status. Adolescent onset is argued to more typically be associated with short-term antisocial behavior.[1]

It has been suggested that the combination of early-onset conduct disorder and ADHD may be associated with life-course-persistent antisocial behaviors as well as psychopathy. There is evidence that this combination is more aggressive and antisocial than those with conduct disorder alone. However, it is not a particularly distinct group since the vast majority of young children with conduct disorder also have ADHD. Some evidence indicates that this group has deficits in behavioral inhibition similar to that of adult psychopaths. They may not be more likely than those with conduct disorder alone to have the interpersonal/affective features and the deficits in emotional processing characteristic of adult psychopaths. Proponents of different types/dimensions of psychopathy have seen this type as possibly corresponding to adult secondary psychopathy and increased disinhibition in the triarchic model.[1]

The DSM-5 includes a specifier for those with conduct disorder who also display a callous, unemotional interpersonal style across multiple settings and relationships. The specifier is based on research which suggests that those with conduct disorder who also meet criteria for the specifier tend to have a more severe form of the disorder as well as a different response to treatment.[1][45] Proponents of different types/dimensions of psychopathy have seen this as possibly corresponding to adult primary psychopathy and increased boldness and/or meanness in the triarchic model.[1]

Three behaviors—bedwetting, cruelty to animals and firestarting, known as the Macdonald triad—were first described by John Macdonald as possible indicators, if occurring together over time during childhood, of future episodic aggressive behavior.[46] However, subsequent research has found that bedwetting is not a significant factor[47] and the triad as a particular profile has been called an urban legend.[48] Questions remain about a connection between animal cruelty and later violence, though it has been included in the DSM as a possible factor in conduct disorder and later antisocial behavior.[49]

Dysfunctions in the prefrontal cortex and amygdala regions of the brain are associated with specific learning impairments in psychopathy.[50][51][52][53] Since the 1980s, scientists have linked traumatic brain injury, including damage to these regions, with violent and psychopathic behavior.[50][51][52] Patients with damage in such areas resembled "psychopathic individuals" whose brains were incapable of acquiring social and moral knowledge; those who acquired damage as children may have trouble conceptualizing social or moral reasoning, while those with adult-acquired damage may be aware of proper social and moral conduct but be unable to behave appropriately.[50][51][52] Dysfunctions in the amygdala and ventromedial prefrontal cortex may also impair stimulus-reinforced learning in psychopaths, whether punishment-based or reward-based.[53] People scoring 25 or higher in the PCL-R, with an associated history of violent behavior, appear to have significantly reduced mean microstructural integrity in their uncinate fasciculus—white matter connecting the amygdala and orbitofrontal cortex.[54] There is DT-MRI evidence of breakdowns in the white matter connections between these two important areas.[54]

Studies also suggest inverse relationships between psychopathy and intelligence, including with regards to verbal IQ.[6][24] Studies indicate that different aspects of the definition of psychopathy (e.g. interpersonal, affective (emotion), behavioral and lifestyle components) can show different links to intelligence, and the result can also depend on the type of intelligence assessment (e.g. verbal, creative, practical, analytical).[6] However, Hare and Neumann state that a large literature demonstrates at most only a weak association between psychopathy and IQ. They consider that the early pioneer Cleckley included good intelligence in his checklist due to selection bias (since many of his patients were "well educated and from middle-class or upper-class backgrounds") and state that "there is no obvious theoretical reason why the disorder described by Cleckley or other clinicians should be related to intelligence; some psychopaths are bright, others less so".[6][55]

A large body of research suggests that psychopathy is associated with atypical responses to distress cues (e.g. facial and vocal expressions of fear and sadness), including decreased activation of the fusiform and extrastriate cortical regions, which may partly account for impaired recognition of and reduced autonomic responsiveness to expressions of fear, and impairments of empathy.[56][57][58][59][60] Studies on children with psychopathic tendencies have also shown such associations.[61][62][63] The underlying biological surfaces for processing expressions of happiness are functionally intact in psychopaths, although less responsive than those of controls.[60][61][62][63] The neuroimaging literature is unclear as to whether deficits are specific to particular emotions such as fear. Some recent fMRI studies have reported that emotion perception deficits in psychopathy are pervasive across emotions (positives and negatives).[64][65]

A recent study on psychopaths found that under certain circumstances, they could willfully empathize with others, and that their empathic reaction initiated the same way it does for controls. Psychopathic criminals were brain-scanned while watching videos of a person harming another individual. The psychopaths' empathic reaction initiated the same way it did for controls when they were instructed to empathize with the harmed individual, and the area of the brain relating to pain was activated when the psychopaths were asked to imagine how the harmed individual felt. The research suggests how psychopaths could switch empathy on at will, which would enable them to be both callous and charming. The team who conducted the study say it is still unknown how to transform this willful empathy into the spontaneous empathy most people have, though they propose it could be possible to bring psychopaths closer to rehabilitation by helping them to activate their "empathy switch". Others suggested that despite the results of the study, it remained unclear whether psychopaths' experience of empathy was the same as that of controls, and also questioned the possibility of devising therapeutic interventions that would make the empathic reactions more automatic.[66]

Work conducted by Professor Jean Decety with large samples of incarcerated psychopaths offers additional insights. In one study, psychopaths were scanned while viewing video clips depicting people being intentionally hurt. They were also tested on their responses to seeing short videos of facial expressions of pain. The participants in the high-psychopathy group exhibited significantly less activation in the ventromedial prefrontal cortex, amygdala and periaqueductal gray parts of the brain, but more activity in the striatum and the insula when compared to control participants.[67] In a second study, individuals with psychopathy exhibited a strong response in pain-affective brain regions when taking an imagine-self perspective, but failed to recruit the neural circuits that were activated in controls during an imagine-other perspective—in particular the ventromedial prefrontal cortex and amygdala—which may contribute to their lack of empathic concern.[68]

Psychopaths may have a different baseline when it comes to empathy.[69] Professor Simon Baron-Cohen suggests that, unlike the combination of both reduced cognitive and affective empathy often seen in those with classic autism, psychopaths are associated with intact cognitive empathy, implying non-diminished awareness of another's feelings when they hurt someone.[70]

Psychopaths have been considered notoriously amoral – an absence of, indifference towards, or disregard for moral beliefs. There are few firm data on patterns of moral judgment. However, studies of developmental level (sophistication) of moral reasoning found all possible results – lower, higher or the same as non-psychopaths. Studies that compared judgments of personal moral transgressions versus judgments of breaking conventional rules or laws, found that psychopaths rated them as equally severe, whereas non-psychopaths rated the rule-breaking as less severe.[71]

A study comparing judgments of whether personal or impersonal harm would be endorsed in order to achieve the rationally maximum (utilitarian) amount of welfare, found no significant differences between psychopaths and non-psychopaths. However, a further study using the same tests found that prisoners scoring high on the PCL were more likely to endorse impersonal harm or rule violations than non-psychopaths were. Psychopaths who scored low in anxiety were also more willing to endorse personal harm on average.[71]

Assessing accidents, where one person harmed another unintentionally, psychopaths judged such actions to be more morally permissible. This result has been considered a reflection of psychopaths' failure to appreciate the emotional aspect of the victim's harmful experience.[72]

In his book The Mask of Sanity, Hervey Cleckley described 16 (21 in the first edition) "common qualities" he thought were characteristic of the individuals he termed psychopaths.[73]

Cleckley stated in the first edition of The Mask of Sanity (p. 257) that those he was calling psychopaths were "frankly and unquestionably psychotic", but in later editions suggested that they are not psychotic according to prevailing definitions. He did not on the whole describe them as particularly hostile or aggressive, contrary to more sinister depictions that others later developed.[55] In addition, he proposed the existence of a milder and extremely common form of the condition: "If we consider, in addition to these patients (nearly all of whom have records of the utmost folly and misery and idleness over many years and who have had to enter a psychiatric hospital), the vast number of similar people in every community who show the same behavior pattern in milder form but who are sufficiently protected and supported by relatives to remain at large, the prevalence of this disorder is seen to be appalling".[73]

Despite possible discrepancies, Cleckley's work on psychopathy may have influenced the PCL-R and the initial diagnostic criteria for antisocial personality reaction/disturbance in the DSM,[citation needed] and some researchers continue to consider Cleckley's clinical profile to be a prominent model of psychopathy.[1]

Studies have identified both genetic and non-genetic contributors to causing psychopathy, including their influences on brain function. Proponents of the triarchic model see psychopathy as due to the interaction of an adverse environment and genetic predispositions. What is adverse may differ depending on the underlying predisposition. Persons having high boldness may respond poorly to punishment but may respond better to rewards and secure attachments.[1][7]

Studies of the personality characteristics typical of psychopaths have found moderate genetic (as well as non-genetic) influences. On the PPI, fearless dominance and impulsive antisociality were similarly influenced by genetics and uncorrelated with each other.[1][74] Genetic factors may generally influence the development of psychopathy while environmental factors affect the specific traits that predominate.[55] A study on a large group of children found more than 60% heritability for "callous-unemotional traits" and that conduct problems among children with these traits had a higher heritability than among children without these traits.[1]

Studies have also suggested a connection between psychopathy and a variant of the monoamine oxidase A (MAO-A) gene (dubbed the "warrior gene").[75][76] In the variant, the allele associated with behavioral traits consists of 30 bases, and produces comparatively less MAO-A enzyme.[77] Low MAO-A activity was found to result in a significantly increased risk of aggression and antisocial behavior.[76][78] The 3R variant (linked to Low MAO-A activity) was found to vary widely in demographic prevalence among different ethnic groups. 59% of African-American men, 56% of Maori men and 54% of Chinese men carry the MOA-A 3R genetic variant, compared to 34% of Caucasians.[79][80]

A study by Farrington of a sample of London males followed between age 8 and 48 included studying which factors scored 10 or more on the PCL:SV at age 48. The strongest factors included having a convicted parent, being physically neglected, low involvement of the father with the boy, low family income, and coming from a disrupted family. Other significant factors included poor supervision, harsh discipline, large family size, delinquent sibling, young mother, depressed mother, low social class, and poor housing.[21] There has also been association between psychopaths and detrimental treatment by peers.[81]

Researchers have linked head injuries with psychopathy and violence.[50][51][52] Since the 1980s, scientists have associated traumatic brain injury, such as damage to the prefrontal cortex, including the orbitofrontal cortex,[82] with psychopathic behavior and an inability to make morally and socially acceptable decisions.[50][52] Children with early damage in the prefrontal cortex may never fully develop social or moral reasoning and become "psychopathic individuals ... characterized by high levels of aggression and antisocial behavior performed without guilt or empathy for their victims".[50][51] Additionally, damage to the amygdala may impair the ability of the prefrontal cortex to interpret feedback from the limbic system, which could result in uninhibited signals that manifest in violent and aggressive behavior.[50]

High levels of testosterone combined with low levels of cortisol and/or serotonin have been theorized as contributing factors. Testosterone is "associated with approach-related behavior, reward sensitivity, and fear reduction". Injecting testosterone "shift[s] the balance from punishment to reward sensitivity", decreases fearfulness, and increases "responding to angry faces". Some studies have found that high testosterone levels are associated with antisocial and aggressive behaviors, yet other research suggests that testosterone alone does not cause aggression but increases dominance-seeking. It is unclear from studies if psychopathy correlates with high testosterone levels, but a few studies have found psychopathy to be linked to low cortisol levels. Cortisol increases "the state of fear, sensitivity to punishment, and withdrawal behavior". Furthermore, high testosterone levels combined with low serotonin levels, which are associated with "impulsive and highly negative reactions", may increase violent aggression when an individual becomes frustrated.[83] Several animal studies note the role of serotonergic functioning in impulsive aggression and antisocial behavior.[84][85][86][87]

Studies have suggested other correlations. Psychopathy was associated in two studies with an increased ratio of HVA (a dopamine metabolite) to 5-HIAA (a serotonin metabolite).[83] Studies have indicated that individuals with the traits meeting criteria for psychopathy show a greater dopamine response to potential "rewards" such as monetary promises or taking drugs such as amphetamines. This has been theoretically linked to increased impulsivity.[88] A 2010 British study found that a large 2D:4D digit ratio, an indication of high prenatalestrogen exposure, was a "positive correlate of psychopathy in females, and a positive correlate of callous affect (psychopathy sub-scale) in males".[89]

Findings have also shown monoamine oxidase A to affect the predictive ability of the PCL-R.[78] Monoamine oxidases (MAOs) are enzymes that are involved in the breakdown of neurotransmitters such as serotonin and dopamine and are, therefore, capable of influencing feelings, mood, and behavior in individuals.[90] Findings suggest that further research is needed in this area.[91][92]

Psychopathy may emerge from an amalgamation of divergent factors. One conceptualization suggests two dichotomous origins, termed primary and secondary psychopathy.[93] Using this model of research, primary psychopaths arise from mostly genetic factors, whereas environmental factors play a stronger role in secondary psychopathy. Some research suggests that secondary psychopaths have high levels of anxiety while primary psychopaths are low-anxiety individuals.[94] There is substantial evidence that anxiety can play a mediating role in many psychopathologies, including psychopathy. However, there is insufficient evidence supporting the etiological processes thought to underlie primary versus secondary psychopathy at this time.[95]

Psychopathy is associated with several adverse life outcomes as well as increased risk of early death due to factors such as homicides, accidents, and suicides. This, in combination with the evidence for genetic influences, is evolutionarily puzzling and may suggest that there are compensating evolutionary advantages. Researchers within evolutionary psychology have proposed several evolutionary explanations. Some psychopaths may possibly be very socially successful. Another is that some associated traits such as early, promiscuous, adulterous, and coercive sexuality may increase reproductive success. A third is that psychopathy represents a frequency-dependent, socially parasitic strategy. This may work as long as there are few other psychopaths in the community since more psychopaths means increasing the risk of encountering another psychopath as well as non-psychopaths likely adapting more countermeasures against cheaters.[1][74][96]

Criticism include that it may be better to look at the contributing personality factors rather than treat psychopathy as a unitary concept due to poor testability and a lack of empirical evidence regarding reproductive success of psychopaths. Furthermore, if psychopathy is caused by the combined effects of a very large number of adverse mutations then each mutation may have so small an effect that it escapes natural selection.[1]

Some laboratory research demonstrate correlations between psychopathy and atypical responses to aversive stimuli, including weak conditioning to painful stimuli and poor learning of avoiding responses that cause punishment, as well as low reactivity in the autonomic nervous system as measured with skin conductance while waiting for a painful stimulus but not when the stimulus occurs. While it has been argued that the reward system functions normally, some studies have also found reduced reactivity to pleasurable stimuli. Psychopaths have also had difficulty switching from an ongoing action despite environmental cues signaling a need to do so. This may explain the difficulty responding to punishment, although it is unclear if it can explain findings such as deficient conditioning. There may be methodological issues regarding the research.[1] While establishing a range of idiosyncrasies on average in linguistic and affective processing under certain conditions, this research program has not confirmed a common pathology of psychopathy.[97]

The amygdala and frontal areas have been suggested as particularly important.[53] People scoring 25 or higher in the PCL-R, with an associated history of violent behavior, appear on average to have significantly reduced microstructural integrity between the white matter connecting the amygdala and orbitofrontal cortex (such as the uncinate fasciculus). The evidence suggested that the degree of abnormality was significantly related to the degree of psychopathy and may explain the offending behaviors.[54] Furthermore, changes in the amygdala have been associated with "callous-unemotional" traits in children. However, the amygdala has also been associated with positive emotions, and there have been inconsistent results in the studies in particular areas, which may be due to methodological issues.[1]

Some of these findings are consistent with other research and theories. For example, in a study of how psychopaths respond to emotional words, widespread differences in activation patterns have been shown across the temporal lobe when criminal psychopaths were compared to "normal" volunteers, which is consistent with views in clinical psychology. Additionally, the notion of psychopathy being characterized by low fear is consistent with abnormalities in the amygdala, since detriments in aversive conditioning and instrumental learning are thought to result from amygdala dysfunction, potentially compounded by orbital frontal cortex dysfunction, although the specific reasons are unknown.[82][99]

Proponents of the primary-secondary psychopathy distinction and triarchic model argue that there are neuroscientific differences between subgroups of psychopaths which support their views. For instance, the boldness factor in the triarchic model is argued to be associated with reduced activity in the amygdala during fearful or aversive stimuli and reduced startle response, while the disinhibition factor is argued to be associated with impairment of frontal lobe tasks. There is evidence that boldness and disinhibition are genetically distinguishable.[1]

Psychopathy is most commonly assessed with the Hare Psychopathy Checklist, Revised (PCL-R) created by Robert Hare, based on Cleckley's criteria from the 1940s, criminological concepts such as those of William and Joan McCord, and his own research on criminals and incarcerated offenders in Canada.[55][100][101] The PCL-R is widely used and is referred to by some as the "gold standard" for assessing psychopathy. [102] There are also numerous criticisms of the PCL as a theoretical tool and in real-world usage.[103][104][105][106][107]

Each of the 20 items in the PCL-R is scored on a three-point scale, with a rating of 0 if it does not apply at all, 1 if there is a partial match or mixed information, and 2 if there is a reasonably good match to the offender. This is said[108] to be ideally done through a face-to-face interview together with supporting information on lifetime behavior (e.g. from case files), but is also done based only on file information. It can take up to three hours to collect and review the information.[1] High PCL-R scores are positively associated with measures of impulsivity and aggression, Machiavellianism, persistent criminal behavior, and negatively associated with measures of empathy and affiliation. Out of a maximum score of 40, the cut-off for the label of psychopathy is 30 in the United States and 25 in the United Kingdom,[1][109] although there is little scientific support for these as particular break points.[citation needed] A cut-off score of 25 is also sometimes used for research purposes.[1]

The PCL-R items were designed to be split in two. Factor 1 involves interpersonal or affective (emotion) personality traits and higher values are associated with narcissism and low empathy as well as social dominance and less fear or depression. Factor 2 involves either impulsive-irresponsible behaviors or antisocial behaviors and is associated with a maladaptive lifestyle including criminality. The two factors correlate with each other to some extent.[1] Each factor is sometimes further subdivided in two: interpersonal versus affect items for Factor 1, and impulsive-irresponsible lifestyle versus antisocial behavior items for Factor 2. "Promiscuous sexual behavior" and "many short-term marital relationships" have sometimes been left out in such divisions.[108]

Some have argued that a three-factor structure may provide a better model than the two-factor structure. Cooke and Michie suggested that those items from Factor 2 strictly relating to antisocial behavior (criminal versatility, juvenile delinquency, revocation of conditional release, early behavioral problems, and poor behavioral controls) should be removed, and that the remaining items be divided into three factors: Arrogant and Deceitful Interpersonal Style, Deficient Affective Experience, and Impulsive and Irresponsible Behavioral Style.[110] Hare and colleagues have published detailed critiques of the model and argue that there are statistical and conceptual problems.[55]

Because scores may have important consequences for an individual's future, the potential for harm if the test is used or administered incorrectly is considerable. The test can only be considered valid if administered by a suitably qualified and experienced clinician under controlled conditions.[108][111] According to Jon Ronson, what makes a suitably qualified and experienced clinician is someone who is trained to administer the PCL-R checklist. The checklist can be misused, especially if the clinician is of a different race than the client and there are different cultural norms that are misinterpreted.[citation needed]

There are additional inventories derived directly from the PCL-R, including the Psychopathy Checklist: Screening Version (PCL:SV) and Psychopathy Checklist: Youth Version (PCL:YV). The PCL:SV was developed as a labor-saving assessment for the same forensic settings as the PCL-R and to meet the needs of settings where clients do not necessarily have criminal records (e.g. civil psychiatric patients). The PCL:YV assesses juvenile psychopathy in children and adolescents.[1]

Unlike the PCL, the Psychopathic Personality Inventory (PPI) was developed to comprehensively index personality traits without explicitly referring to antisocial or criminal behaviors themselves. It is a self-report scale that was developed originally for non-clinical samples (e.g. university students) rather than prisoners, though may be used with the latter. It was revised in 2005 to become the PPI-R and now comprises 154 items organized into eight subscales.[112] The item scores have been found to group into two overarching and largely separate factors (unlike the PCL-R factors), plus a third factor which is largely independent on scores on the other two:[1] Factor I is associated with social efficacy while Factor 2 is associated with maladaptive tendencies. A person may score at different levels on the different factors, but the overall score indicates the extent of psychopathic personality.[1]

The first edition of the DSM in 1952 had a section on sociopathic personality disturbances, then a general term that included such things as homosexuality and alcoholism as well as an "antisocial reaction" and "dyssocial reaction". The latter two eventually became antisocial personality disorder (ASPD) in the DSM and dissocial personality disorder in the ICD.[citation needed] Both manuals have stated that their diagnoses have been referred to, or include what is referred to, as psychopathy or sociopathy, although neither diagnostic manual has ever included a disorder officially titled as such.[1][2][3]

Researchers such as Robert Hare and Stephen Hart regard the mainstream psychiatric view as deeply flawed, calling for a return to a traditional model of psychopathy as a distinct disorder.[2][page needed]

Antisocial personality disorder (ASPD), the criteria of which were based on American psychiatrist Hervey Cleckley's work[citation needed] on psychopathy, is described in the DSM-IV-TR as "... a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. This pattern has also been referred to as psychopathy, sociopathy, or dissocial personality disorder".[2][3][113]

A diagnosis of ASPD is based largely on explicit behavioral patterns, whereas measurement tools such as the PCL or PPI also largely, or solely, rely on judgment or self-reports of personality traits.[1][114][115] The diagnostic criteria for ASPD focus relatively less on personality traits partly due to the belief that such traits are difficult to measure reliably and it is "easier to agree on the behaviors that typify a disorder than on the reasons why they occur".[114][115] As a result, critics have argued that psychopathy and ASPD are not synonymous, despite the DSM's statement that ASPD has been referred to as psychopathy.[1][2][3][109][114][115]

Nonetheless, psychopathy has been proposed as a specifier under an alternative model for ASPD. In the DSM-5, under "Alternative DSM-5 Model for Personality Disorders", ASPD with psychopathic features is described as characterized by "a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors (e.g., fraudulence)". Low levels of withdrawal and high levels of attention-seeking combined with low anxiety are associated with "social potency" and "stress immunity" in psychopathy.[116]:765 Under the specifier, affective and interpersonal characteristics are comparatively emphasized over behavioral components.[117]

The ICD defines a conceptually similar or equivalent disorder to ASPD called dissocial personality disorder, "usually coming to attention because of a gross disparity between behaviour and the prevailing social norms, and characterized by" at least 3 of 6 specific issues. The manual states that its diagnosis includes "amoral, antisocial, asocial, psychopathic, and sociopathic personality (disorder)".[4][118]

It has been suggested that psychopathy may be comorbid with several other conditions than these,[124] but limited work on comorbidity has been carried out. This may be partly due to difficulties in using inpatient groups from certain institutions to assess comorbidity, owing to the likelihood of some bias in sample selection.[119]

Several researchers have argued that there exist two variants of psychopathy. There is also empirical support for separating persons scoring high on the PCL-R into two groups that do not simply reflect Factor 1 and Factor 2. There is at least preliminary evidence of differences regarding cognition and affect as measured in laboratory tests. Different theories characterize these two variants somewhat differently.[1]

Compared to "primary" psychopaths, "secondary" psychopaths have been characterized as having more fear, anxiety, and negative emotions. They are often seen as more impulsive and with more reactive anger and aggression. David T. Lykken, using Gray's biopsychological theory of personality, argued that primary psychopaths innately have little fear while secondary psychopaths innately have increased sensitivity to rewards.[1] Studies also suggest that secondary psychopaths manifest more borderline personality features than do primary psychopaths, and comparable levels of antisocial behavior.[125]

There are also different theories as to the predominant causes of either variant. Some researchers, such as Benjamin Karpman, believe that primary psychopaths are born with an emotional deficit and that secondary psychopaths acquire it through adverse environmental experiences, although others, such as Lykken, link both variants to biological predispositions. Some preliminary research suggests that secondary psychopaths may have had a more abusive childhood, a higher risk of future violence, and potentially a better response to treatment.[1]

Results of a study on male patients at a maximum-security forensic hospital suggested four potential subtypes of psychopathy: narcissistic, borderline, sadistic, and antisocial. The researchers have stated that additional data are needed to understand the observed variations.[126]

Research on psychopathy has largely been done on men and the PCL-R was developed using mainly male criminal samples, raising the question of how well the results apply to women. There have also been research investigating the sex differences. Men score higher than women on both the PCL-R and the PPI and on both of their main scales. The differences tend to be somewhat larger on the interpersonal-affective scale than on the antisocial scale. Most but not all studies have found broadly similar factor structure for men and women.[1]

Many associations with other personality traits are similar, although in one study the antisocial factor was more strongly related with impulsivity in men and more strongly related with openness to experience in women. It has been suggested that psychopathy in men manifest more as an antisocial pattern while in women it manifests more as a histrionic pattern. Studies on this have shown mixed results. PCL-R scores may be somewhat less predictive of violence and recidivism in women. On the other hand, psychopathy may have a stronger relationship with suicide and possibly internalizing symptoms in women. A suggestion is that psychopathy manifests more as externalizing behaviors in men and more as internalizing behaviors in women.[1]

Psychopathy has often been considered untreatable. Harris and Rice's Handbook of Psychopathy says that there is little evidence of a cure or effective treatment for psychopathy; no medications can instill empathy, and psychopaths who undergo traditional talk therapy might become more adept at manipulating others and more likely to commit crime.[127] Some studies suggest that punishment and behavior modification techniques may not improve the behavior of psychopaths.[127]

Although highly psychopathic individuals are likely to be highly treatment-resistant, it has been noted that the treatments most likely to be effective are those that focus on self-interest and the tangible, material value of prosocial behavior, with interventions that develop skills to obtain what a person wants out of life in prosocial rather than antisocial ways.[128][129]

Psychiatric medications may also alleviate conditions sometimes associated with the disorder or with symptoms such as aggression, including antipsychotic, antidepressant or mood-stabilizing medications, although none have yet been approved by the FDA for this purpose.[1][2][3][117][130]

The PCL-R, the PCL:SV, and the PCL:YV are highly regarded and widely used in criminal justice settings, particularly in North America. They may be used for risk assessment and for assessing treatment potential and be used as part of the decisions regarding bail, sentence, which prison to use, parole, and regarding whether a youth should be tried as a juvenile or as an adult. There have been several criticisms against this. They include the general criticisms against the PCL-R, the availability of other risk assessment tools which may have advantages, and excessive pessimism regarding prognosis and treatment possibilities.[1]

The interrater reliability of the PCL-R can be high when used carefully in research but tend to be poor in applied settings. In particular Factor 1 items are somewhat subjective. In sexually violent predator cases the PCL-R scores given by prosecution experts were consistently higher than those given by defense experts in one study. The scoring may also be influenced by other differences between raters. In one study it was estimated that of the PCL-R variance, about 45% was due to true offender differences, 20% was due to which side the rater testified for, and 30% was due to other rater differences.[1]

In the United Kingdom, "psychopathic disorder" was legally defined in the Mental Health Act (UK), under MHA1983,[109][131] as "a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned". This term was intended to reflect the presence of a personality disorder in terms of conditions for detention under the Mental Health Act 1983. With the subsequent amendments to the Mental Health Act 1983 within the Mental Health Act 2007, the term "psychopathic disorder" has been abolished, with all conditions for detention (e.g. mental illness, personality disorder, etc.) now being contained within the generic term of "mental disorder".[citation needed]

Starting in the 1930s, before some modern concepts of psychopathy were developed, "sexual psychopath" laws were introduced by some states, and by the mid-1960s more than half of the states had such laws. "Sexual psychopaths" were seen as a distinct group of sex offenders who were not seriously mentally ill but had a "psychopathic personality" that could be treated. This was in agreement with the general rehabilitative trends at this time. Courts sent such sex offenders to a mental health facility for community protection and treatment.[133]

Starting in 1970, many of these laws were modified or abolished in favor of more traditional responses such as imprisonment due to criticism of the "sexual psychopath" concept as lacking scientific evidence, the treatment being ineffective, and predictions of future offending being dubious. There were also a series of cases where persons treated and released committed new sex crimes. Starting in the 1990s, several states have passed sexually dangerous person laws, including registration, housing restrictions, public notification, mandatory reporting by health care professionals, and civil commitment, which permits indefinite confinement after a sentence has been completed.[133] Psychopathy measurements may be used in the confinement decision process.[1]

The only study finding increased criminal recidivism after treatment was in a 2011 retrospective study of a treatment program in the 1960s that had several methodological problems likely not approved today. Some relatively rigorous quasi-experimental studies using more modern treatment methods have found improvements regarding reducing future violent and other criminal behavior, regardless of PCL-R scores, although none were randomized controlled trials. Various other studies have found improvements in risk factors for crime such as substance abuse. No study had in a 2011 review examined if the personality traits could be changed by such treatments.[1]

A 2008 study using the PCL:SV found that 1.2% of a US sample scored 13 or more out of 24, indicating "potential psychopathy". The scores correlated significantly with violence, alcohol use, and lower intelligence.[24] A 2009 British study by Coid et al., also using the PCL:SV, reported a community prevalence of 0.6% scoring 13 or more. The scores correlated with younger age, male gender, suicide attempts, violence, imprisonment, homelessness, drug dependence, personality disorders (histrionic, borderline and antisocial), and panic and obsessive–compulsive disorders.[134]

Robert Hare has stated that many male psychopaths have a pattern of mating with and quickly abandoning women, and thereby have a high fertility rate, resulting in children that may inherit a predisposition to psychopathy.[81] However, empirical evidence regarding the reproductive success of psychopaths is lacking.[1]

Psychopathy in the workplace is a serious issue as, although psychopaths typically represent only a small percentage of the staff, they are most common at higher levels of corporate organizations and their detrimental effects (for example, increased bullying, conflict, stress, staff turnover, absenteeism, reduction in productivity) often causes a ripple effect throughout an organization, setting the tone for an entire corporate culture.[135]

Hare reports that about 1 per cent of the general population meets the clinical criteria for psychopathy.[136] Hare further claims that the prevalence of corporate psychopaths is higher in the business world than in the general population. Figures of around 3-4% have been cited for more senior positions in business.[137] Unfortunately, even with this small percentage, corporate psychopaths can do enormous damage when they are positioned in senior management roles.[138]

The word psychopathy is a joining of the Greek words psyche (ψυχή) "soul" and pathos (πάθος) "suffering, feeling".[143] The first documented use is from 1847 in Germany as psychopatisch,[144] and the noun psychopath has been traced to 1885.[145] In medicine, patho- has a more specific meaning of disease (thus pathology has meant the study of disease since 1610, and psychopathology has meant the study of mental disorder in general since 1847. A sense of "a subject of pathology, morbid, excessive" is attested from 1845,[146] including the phrase pathological liar from 1891 in the medical literature).

The term psychopathy initially had a very general meaning referring to all sorts of mental disorders and social aberrations, popularised from 1891 in Germany by Koch's concept of "psychopathic inferiority" (psychopathische Minderwertigkeiten). Some medical dictionaries still define psychopathy in both a narrow and broad sense, such as MedlinePlus from the U.S. National Library of Medicine.[147] On the other hand, Stedman's Medical Dictionary defines psychopathy only as an outdated term for an antisocial type of personality disorder.[148]

The term psychosis was also used in Germany from 1841, originally in a very general sense. The suffix -ωσις (-osis) meant in this case "abnormal condition". This term or its adjective psychotic would come to refer to the more severe mental disturbances and then specifically to mental states or disorders characterized by hallucinations, delusions or in some other sense markedly out of touch with reality.[149]

The slangpsycho has been traced to a shortening of the adjective psychopathic from 1936, and from 1942 as a shortening of the noun psychopath,[150] but it is also used as shorthand for psychotic or just mentally crazed in some way.[151]

The label psychopath has been described as nonspecific but probably persisting because it indicates that the source of behavior lies in the psyche rather than in the situation. The media usually uses the term to designate any criminal whose offenses are particularly abhorrent and unnatural, but that is not its original or general psychiatric meaning.[152]

The word element socio has been used in compound words since around 1880.[153][154] The term sociopathy may have been first introduced in 1909 in Germany by biological psychiatrist Karl Birnbaum and in 1930 in the US by educational psychologist George E. Partridge, as an alternative to the concept of psychopathy.[153] It was used to indicate that the defining feature is violation of social norms, or antisocial behavior, and has often also been associated with postulating social as well as biological causation.[155][156][157][158]

There are various contemporary usages of the term. Robert Hare claimed in a 1999 popular science book that sociopathy and psychopathy are often used interchangeably, but in some cases the term sociopathy is preferred because it is less likely than is psychopathy to be confused with psychosis, whereas in other cases which term is used may "reflect the user's views on the origins and determinates of the disorder". Hare contended that the term sociopathy is preferred by those that see the causes as due to social factors and early environment, and the term psychopathy preferred by those who believe that there are psychological, biological, and genetic factors involved in addition to environmental factors.[81] Hare also provides his own definitions: he describes psychopathy as not having a sense of empathy or morality, but sociopathy as only differing in sense of right and wrong from the average person.[159][160]

The concept of psychopathy has been indirectly connected to the early 1800s with the work of Pinel (1801; "mania without delirium") and Pritchard (1835; "moral insanity"), although historians have largely discredited the idea of a direct equivalence.[161] The term psychopathic was coined toward the end of the 19th century, by the German psychiatrist Julius Koch (1891). In contrast with current usage, Koch applied the term psychopathic inferiority (psychopathischen Minderwertigkeiten) to various chronic conditions and character disorders.[1][162]

The term psychopathic came to be used to describe a diverse range of dysfunctional or antisocial behavior and mental and sexual deviances, including at the time homosexuality. It was often used to imply an underlying "constitutional" or genetic origin. Disparate early descriptions likely set the stage for modern controversies about the definition of psychopathy.[1]

An influential figure in shaping modern American conceptualizations of psychopathy was American psychiatrist Hervey Cleckley. In his classic monograph, The Mask of Sanity (1941), Cleckley drew on a small series of vivid case studies of psychiatric patients at a Veterans Administration hospital in Georgia to describe the disorder. Cleckley used the metaphor of the "mask" to refer to the tendency of psychopaths to appear confident, personable, and well-adjusted compared to most psychiatric patients, while revealing underlying pathology through their actions over time. Cleckley formulated sixteen criteria to describe the disorder.[1] The Scottish psychiatrist David Henderson had also been influential in Europe from 1939 in narrowing the diagnosis.[163]

The diagnostic category of sociopathic personality in early editions of the Diagnostic and Statistical Manual (DSM)[113] had some key similarities to Cleckley's ideas, though in 1980 when renamed Antisocial Personality Disorder some of the underlying personality assumptions were removed.[2] In 1980, Canadian psychologist Robert D. Hare introduced an alternative measure, the "Psychopathy Checklist" (PCL) based largely on Cleckley's criteria, which was revised in 1991 (PCL-R),[108] and is the most widely used measure of psychopathy.[164] There are also several self-report tests, with the Psychopathic Personality Inventory (PPI) used more often among these in contemporary adult research.[1]

Famous individuals have sometimes been diagnosed, albeit at a distance, as psychopaths. As one example out of many possible from history, in a 1972 version of a secret report originally prepared for the Office of Strategic Services in 1943, and which may have been intended to be used as propaganda,[165][166] non-medical psychoanalystWalter C. Langer suggested Adolf Hitler was probably a psychopath.[167] However, others have not drawn this conclusion; clinical forensic psychologist Glenn Walters argues that Hitler's actions do not warrant a diagnosis of psychopathy as, although he showed several characteristics of criminality, he was not always egocentric, callously disregarding of feelings or lacking impulse control, and there is no proof he couldn't learn from mistakes.[168]

^The term "psychopath" may be used in research without sufficient clarification on whether the intended meaning of the term in context is someone who is "relatively psychopathic" in this manner. Therefore it is important to note that where "psychopath" is used elsewhere in this article, it implies only the meaning intended by any authors referenced, which may not necessarily entail someone that is psychopathic relative to others along a continuum.

^Walters, Glenn D. (2004). "The Trouble with Psychopathy as a General Theory of Crime". International Journal of Offender Therapy and Comparative Criminology48 (2): 133–48. doi:10.1177/0306624X03259472. PMID15070462.

^ abHildebrand, Martin; De Ruiter, Corine (2004). "PCL-R psychopathy and its relation to DSM-IV Axis I and II disorders in a sample of male forensic psychiatric patients in the Netherlands". International Journal of Law and Psychiatry27 (3): 233–48. doi:10.1016/j.ijlp.2004.03.005. PMID15177992.

^James O Office Politics: How to Thrive in a World of Lying, Backstabbing and Dirty Tricks (2013)

^Boddy. C. R (2005) "’The Implications for Business Performance and Corporate Social Responsibility of Corporate Psychopaths" in 2nd International Conference on Business Performance and Corporate Social Responsibility, ed. M. Hopkins, Middlesex University Business School, London

^Hare R D Without Conscience: The Disturbing World of the Psychopaths Among Us 1993